Spinal Bleeding with Brain Injury May Suggest Abuse

The radiologic features of abusive head trauma include bleeding within the skull and brain injury. Spinal injuries like spinal subdural haemorrhage - bleeding in the space between the spinal cord and its tough outer membrane - are another feature of trauma that may be overlooked clinically in non-fatal cases because of coexistent brain injury and traumatic coma.

"Imaging the whole spine is important in cases of abuse for two reasons," said Doctor Arabinda Kumar Choudhary, paediatric radiologist at Penn State Milton S. Hershey Medical Centre and Penn State College of Medicine in Hershey. "Most of the spinal injuries in abusive head trauma are clinically silent because of extensive injuries elsewhere and lack of a clinical history suggestive of spinal injury. It is important to rule out any significant injury to the spine and spinal cord. Also, spine imaging allows complications of subdural haemorrhage collecting in the spinal canal to be diagnosed earlier."

To study the incidence of spinal subdural haemorrhage, Choudhary and colleagues looked at clinical data and imaging records for 252 children aged two years old or younger who underwent treatment for abusive head trauma at the medical centre. Imaging results included computed tomography (CT) and MRI of the brain, spine, chest, abdomen and pelvis. They compared the imaging results to those from a group of 70 similarly aged children who were treated for accidental trauma.

Spinal canal subdural haemorrhage was evident in more than 60 per cent of the children with abusive head trauma who underwent thoracolumbar imaging, or imaging of the thorax and the lumbar regions of the spine. In contrast, spinal canal subdural haemorrhage was rare in accidental trauma. Only one of the 70 children in the accidental trauma group had spinal subdural haemorrhage.

Choudhary indicated that more research is needed to improve understanding of the relationship between abusive trauma and spinal bleeding and provide another tool for criminal investigators.
"The diagnosis of abusive head trauma is complex," Choudhary said. "In most of these cases, the history does not fit with the clinical findings. The pathophysiology and diagnosis of abusive head trauma are still being hotly debated, particularly in the courts."